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Ann Thorac Surg 2000;70:1246-1250
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Reconstruction of the ascending aorta and aortic root: experience in 45 consecutive patients

^a Cliniques Universitaires Saint-Luc, Brussels, Belgium

Address reprint requests to Dr El Khoury, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, B–1200 Brussels, Belgium
e-mail: elkhoury{at}chir.ucl.ac.be

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Background. Patients with aneurysms of the ascending aorta or aortic root may have associated aortic insufficiency (AI). We reviewed our experience with aortic root remodeling and reconstruction of the sino-tubular junction.

Methods. Forty-five patients were operated on between July 1995 and September 1998. Transesophageal echocardiography showed AI grade III or IV in 15 patients. Twenty-seven patients had replacement of all three sinuses, 10 of one or two sinuses. Reconstruction of the sino-tubular junction alone was performed in 8 patients.

Results. There was one death at 28 days. Perioperative transesophageal echocardiography showed no or discrete AI in all patients. There has been one aortic valve replacement at day 4 postoperatively for cusp repair failure. Transesophageal echocardiography in 40 patients at a mean time of 12.5 months showed no progression of AI in 38 patients, and a grade II in 2. Clinical follow-up averaged 14.5 months. There have been three late, not procedure-related deaths. Thirty-six patients are in New York Heart Association functional class I. There have been no cases of endocarditis.

Conclusions. Aortic remodeling is successful in eliminating AI in patients with aortic root disease with minimal mortality and morbidity. Early echocardiography (1 year) has shown no progression of AI in 95% of cases.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Aortic valve insufficiency may be caused by abnormalities of the leaflets, the root, or a combination of both. In some patients, the disease is confined to the aorta, the leaflets remaining anatomically normal. In these patients, progressive dilatation of the aortic annulus, sinuses, and sino-tubular junction results in outward displacement of the commissures and cusps, which then results in valvular incompetence [1, 2]. Conventional treatment for these patients is composite replacement of the aortic valve and ascending aorta [3]. Despite the success of this operation, complications, including thromboembolism, endocarditis, and problems related to the long-term anticoagulation [4] required, have provided the impetus for the development of a surgical procedure that preserves the native aortic valve. Remodeling of the aortic root was originally described by Sarsam and Yacoub [5] and David [6], and variations of it have been used by other authors [7]. This article describes our experience in this field, and the early clinical and echocardiographic results obtained.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Forty-five patients who underwent aortic root remodeling were identified from the surgical database of our unit from July 1995 to September1998. Retrospective analysis was made from case notes of the preoperative variables, the operative procedures, and mortality and morbidity occurring during the hospital stay. Prospective follow-up of all patients was achieved by telephone questionnaire to both the patients and their referring cardiologists. Written requests were made to individual cardiologists regarding the echocardiographic follow-up. Statistical analysis of postoperative changes measured at echocardiography was made using a two-tailed paired Student’s t test. Statistical significance was defined as p less than 0.05.

Preoperative data
The mean age of the patients was 56.5 years (range, 13 to 76 years) and 60% were male. Twenty patients were in New York Heart Association class III or IV, 11 were in class II, and 14 patients were in functional class I. Thirteen patients were operated on for type A aortic dissection; 10 were acute and 3, chronic. One of these had previously had replacement of both the ascending and descending aorta and presented with a false aneurysm and redissection in the residual proximal aorta, and another had had a coronary artery bypass grafting operation 3 years before. Nine patients had manifestations of the Marfan syndrome. Preoperative transesophageal echocardiography showed aortic incompetence (AI) grade III or IV in 15 patients, grade I or II in 24 patients, and no AI in 6. The mean maximum aortic diameter was 60 mm (range, 49 to 80 mm), and 3 patients had an annular diameter of more than 28 mm(Tables 1–4).

View larger version (110K): [in this window] [in a new window]   Fig 1. Technique of aortic annuloplasty. (Reproduced, with the permission of the BMJ Publishing Group, from Underwood MJ, El Khoury G, Deronck D, Glineur D, Dion R. The aortic root: structure, function, and surgical reconstruction. Heart 2000;83:376–80.)

Occasionally, performing an annuloplasty may distort the geometry of the root, but this was compensated for by performing a commissuroplasty at the commissure between the right and left coronary leaflets. To determine the most appropriate diameter graft for a patient with annular dilatation, the length of the free edges of the aortic valve leaflets were measured and averaged. A graft 10% smaller than these combined lengths was then chosen. Three equidistant marks were then made on the graft, and other authors suggest the graft should then be incised vertically along these marks for a length of approximately two thirds of the graft diameter [7]. To more accurately estimate the length of these incisions on the graft however, we find it easier to suspend the aortic valve commissures with Prolene (Ethicon, Somerville, NJ) sutures and measure their height (Fig 2). The vertical incisions in the graft were made slightly longer than this measurement, and the graft was scalloped so as to reproduce the crescent shape of the annulus and to create pseudosinuses in the supravalvular region. The aortic commissures were then sutured to the appropriate position on the graft, and the intervening polyethylene terephthalate fiber was sutured to the remnants of the aortic sinuses (Fig 3). Because the perimeter of each scalloped area of the graft is longer than the scalloped aortic annulus, it is important that sutures are placed wider along the graft than along the annulus to create neo-sinuses of Valsalva. To achieve this, suturing was commenced at the level of the commissures. The coronary arteries were then reimplanted, and the graft was anastomosed to the distal aorta in conventional fashion (Fig 4).

View larger version (142K): [in this window] [in a new window]   Fig 2. Measurement of commissures. (Reproduced, with the permission of the BMJ Publishing Group, from Underwood MJ, El Khoury G, Deronck D, Glineur D, Dion R. The aortic root: structure, function, and surgical reconstruction. Heart 2000;83:376–80.)

View larger version (130K): [in this window] [in a new window]   Fig 3. Graft Implantation. (Reproduced, with permission of the BMJ Publishing Group, from Underwood MJ, El Khoury G, Deronck D, Glineur D, Dion R. The aortic root: structure, function, and surgical reconstruction. Heart 2000;83:376–80.)

View larger version (99K): [in this window] [in a new window]   Fig 4. Finished remodelling procedure. (Reproduced, with permission of the BMJ Publishing Group, from Underwood MJ, El Khoury G, Deronck D, Glineur D, Dion R. The aortic root: structure, function, and surgical reconstruction. Heart 2000;83:376–80.)

In patients with acute type A dissection, all diseased sinuses (dissected or dilated) were eventually excised, but the dissected area was first repaired with Cardial surgical glues (Saint Etieme, France) to render the annulus and commissures strong enough for suturing. In all acute dissections, the aortic arch was inspected during a period of circulatory arrest and replaced if necessary. Once completed, perfusion was instituted antegradely. Aortic remodeling was therefore decided on independently of any additional distal procedure required and did not have any bearing on the circulatory arrest time.

Operative procedures
Twenty-seven patients underwent remodeling and excision of all three sinuses. In 6 patients, only the noncoronary sinus was replaced, in 3 patients, the noncoronary and right coronary sinuses, and in one patient, the right coronary sinus only. Reconstruction of the sino-tubular junction alone was performed in 8 patients. In 3 patients, the measured annular diameter was more than 28 mm, and an annuloplasty was performed as described. Three patients had a bicuspid aortic valve, and this was repaired at the same time by resection of the median raphe. Coronary artery bypass grafting was performed in 3 patients, mitral valve repair in 8, tricuspid valve repair in 1, aortic cusp repair in 6 (cusp resuspension, triangular resection, decalcification), and 1 patient had an elephant trunk procedure.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment References

One patient required aortic valve replacement at day 4 for AI grade IV because of cusp repair failure (triangular resection). Echocardiography performed at a mean of 10 days postoperatively showed no or discrete AI in 44 patients.

Late mortality, morbidity, and echocardiographic findings
Clinical follow-up averaged 14.5 months (range, 1 to 34 months). Ninety percent of patients were in New York Heart Association functional class I, 10% in class II. Two patients with associated mitral valve disease were treated with anticoagulants because of atrial fibrillation. There have been no reoperations after discharge nor cases of endocarditis. There have been three late deaths. One patient died 4 months postoperatively of liver failure (chronic hepatitis), 1 patient died at 12 months postoperatively because of a cerebral hemorrhage, in the absence of anticoagulation, and 1 patient died at 14 months of an unknown cause.

The 40 survivors consented to repeat echocardiography at a mean postoperative interval of 12.5 months (range, 1 to 30 months). Thirty-eight patients had no or discrete AI; 2 patients had grade II.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment References

Previously published data show that, overall, this procedure does not have a significantly higher mortality than root replacement, and the postoperative complication rates are reassuringly low. Yacoub and colleagues have performed the procedure in 151 patients since 1979 [12]. They report no operative deaths and an early (30-day) mortality of 1.3% for elective cases and 12.2% for emergency operations. Their follow-up period for this group of patients ranges from 1 to 209 months, with a mean of 79 months. The actuarial survival at 5, 10, and 15 years is 92.4%, 87.2%, and 70.4%, respectively, and, importantly, the probability of freedom from reoperation at 5 and 10 years is 95.7% and 90.7%, respectively. No patient required anticoagulation, and there were no reported instances of endocarditis or thromboembolism.

Follow-up echocardiography has shown mild or no aortic regurgitation in 93% of patients, moderate in just more than 5%, and, at the time of reporting, only 1 patient was awaiting reoperation. Echocardiography also demonstrated that the reduction in left ventricular end-systolic and end-diastolic dimensions was maintained throughout the follow-up period.

Gott and colleagues [4] and David [6] have published a series of 101 cases. There were two operative deaths, both caused by cardiac failure. The remaining 99 patients have been followed up for a mean of 31 months (range, 3 to 108 months). There were five late deaths: one sudden, one caused by cerebral bleed, and three unrelated to cardiovascular disease. Sixty-seven patients have none or grade I aortic regurgitation. In this study, 28 patients had Marfan syndrome. Aortic annuloplasty was performed in 11 patients who had remodeling of all three aortic sinuses, and in 28 patients who had reimplantation of the aortic valve. There has been only one failure in a young patient who had a growth spurt of 35 cm in more than 2 years; the aortic valve became stenotic and incompetent because of a relatively small polyethylene terephthalate fiber tube.

After these original publications, a report by Cochran and colleagues [7] of a series of 10 patients appeared, in which they adopted a slight technical modification of the procedure to enhance the creation of neo-sinuses, which was adopted in our series. They reported no operative mortality, and follow-up averaged 13.3 months. All patients are in New York Heart Association functional class I or II. Echocardiography at 6 months postoperatively has shown no progression of regurgitation in any patient and confirmed the optimal appearance of the neo-sinuses.

Another concern is the use of this technique in patients with the Marfan syndrome because of the potential for ongoing annular dilatation and valvular degeneration. Our results, and those of the other proponents of this technique [13], have not identified a particular problem in this group of patients. Because of these concerns, however, it may be that inclusion of an annuloplasty for all Marfan syndrome patients becomes an accepted technique to prevent subsequent annular dilatation.

Other contraindications agreed on by the proponents of this technique include patients with deformed valve leaflets or bicuspid aortic valves [4]. We were able to combine resection of a median raphe with a remodeling procedure in our series, with a good result, and currently do not view this as a contraindication to aortic remodeling, as long as a good result can be obtained with the associated leaflet procedure.

Acute aortic dissection must be considered as a good indication for aortic root remodeling. Because of our experience in aortic root remodeling and because of the risk of redissection of the diseased tissue left behind, our approach to acute aortic dissection type A is quite clear: if the aortic root is unaffected, a supracoronary replacement of the dissected ascending aorta is indicated. If the aortic root is involved in the dissection or dilated, and provided that aortic cusps are normal or nearly normal, remodeling by excising all diseased tissues is indicated. The only issue is the fragility of the dissected aortic tissue where the adventitia is separated from the media. GRF glue has been used for several years to preserve the aortic root as described by Guilmet and associates [14]. However, in our experience, redissection occurred in 3 of 25 patients when aortic root had been preserved by gluing.

This prompted us to favor the aortic root remodeling after gluing it to reinforce the aortic annulus and commissural areas. GRF is applied in the same manner so as to preserve aortic root, but when the glue is solidified, we scallop the aortic root. We have used this technique in the last 13 dissections, and we are very satisfied with the results. If the aortic leaflets are diseased, we do replace the aortic root with a composite graft.

Endocarditis has been reported as being the most common late complication of conventional root replacement [4], but so far, no author has reported a case of endocarditis after aortic remodeling. Thromboembolism has also been reported after root replacement in the setting of inadequate anticoagulation [4], a problem eliminated by the valve-sparing procedure.

Surgical reconstruction of the aortic root for patients with aortic dilatation and associated valvular incompetence has been adopted as a surgical technique in preference to root replacement by a few active proponents of this procedure. Early results are encouraging and the problems of endocarditis and thromboembolism seen in patients after conventional surgery seem to have been virtually eliminated. Long-term follow-up is now required by all groups performing this procedure to establish its durability and substantiate its purported advantages over root replacement.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Footnotes Abstract Introduction Material and methods Results Comment References

 

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3. Bentall H.H., de Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-339.[Abstract/Free Full Text]
4. Gott V.L., Laschinger J.C., Cameron D.E., et al. The Marfan syndrome and the cardiovascular surgeon. Eur J Cardiovasc Surg 1996;10:149-158.
5. Sarsam M.A.I., Yacoub M. Remodeling of the aortic annulus. J Thorac Cardiovasc Surg 1993;105:435-438.[Abstract]
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7. Cochran R.P., Kunzelman K.S., Eddy A.C., Hofer B.O., Verrier E.D. Modified conduit preparation creates a pseudosinus in an aortic valve-sparing procedure for aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1995;109:1049-1058.
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9. Bellhouse B.J., Bellhouse F., Abbot J.A., et al. Mechanism of valvular incompetence in aortic sinus dilatation. Cardiovasc Res 1973;7:490-494.[Medline]
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12. Yacoub M.H., Gehle P., Chandrasekaran V., Birks E.J., Child A., Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080-1090.[Abstract/Free Full Text]
13. David T.E. Aortic valve repair in patients with Marfan’s syndrome and ascending aorta aneurysms due to degenerative disease. J Card Surg 1994;9(Suppl):182-187.[Medline]
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This Article Abstract Full Text (PDF) Online Discussion Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gebrine A. El Khoury Malcolm J. Underwood Robert A. Dion Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by El Khoury, G. A. Articles by Dion, R. A. Search for Related Content PubMed PubMed Citation Articles by El Khoury, G. A. Articles by Dion, R. A.